ORIGINAL ARTICLE
Bali Journal of Anesthesiology (BJOA) 2017, Volume 1, Number 1: 10-12
E-ISSN: 2549-2276
Published by DiscoverSys
1
Professor, 2-8Senior Lecturer,
9-10
Resident, Department of
Anesthesiology, Pain Management
and Intensive Care, Udayana
University, Sanglah General
Hospital, Denpasar-Bali, Indonesia
*
Correspondence to: Dr. Andi Kusuma
Wijaya, Resident of Anesthesiology,
Pain Management and Intensive
Care, Udayana University, Sanglah
General Hospital, Kesehatan Street
No 1 Denpasar-Bali, Indonesia
Ph/Fax: +62 361 257361/235980
anesthesiology@unud.ac.id
10
Effectiveness of infusion warmer use to
prevent hypothermia and shivering after
general anesthesia
Made Wiryana,1 I Ketut Sinardja,2 I Gede Budiarta,3 Tjokorda Gde Agung Senapathi,4
Made Widnyana,5 I Wayan Aryabiantara,6 I Gusti Agung Gede Utara Hartawan,7
Pontisomaya Parami,8 Andi Kusuma Wijaya,9* Adinda Putra Pradhana10
ABSTRACT
Introduction: Shivering and hypothermia after general anesthesia is
a common complication in the recovery room. Heating methods and
certain drugs are widely used, but may not be effective. The purpose of
this study was to evaluate the effectiveness of using infusion warmer
in maintaining normal core temperature and prevent shivering after
general anesthesia.
Material and Methods: The study was a non-blind randomized
control trial study. Research conducted at the Sanglah General Hospital
in October 2016. Fifty-eight people met the inclusion and exclusion
criteria. They were divided into two groups of 29 patients, Group
A (with infusion warmer) and Group B (without infusion warmer).
Multiple parameters were recorded: vital signs, hemodynamic,
Keywords: hypothermia, shivering, infusion warmer, general anesthesia.
Cite This Article: Wiryana M, Sinardja IK, Budiarta IG, Senapathi TGA, Widnyana M, Aryabiantara IW, Hartawan IGAGU, Parami P, Wijaya AK,
Pradhana AP. 2017. Bali Journal of Anesthesiology 1(1): 10-12. DOI:10.15562/bjoa.v1i1.3
INTRODUCTION
Complications after anaesthetic procedure is caused
by three factors: anesthesia, surgery, and co-existing
diseases. One of many complications seen during
recovery after general anaesthesia are hypothermia
and shivering. Shivering is an unpleasant condition
which usually occur as a complication after both
general and regional anaesthesia in patient under-
went either elective or emergency surgery.1,2,3
Post-surgical shivering may cause several
unwanted complications such as physiological
stress, increased oxygen demand by 2-3 times,
increased metabolism, increased intracranial and
intraocular pressure, elevating carbondioxide
production, cathecolamine release, and increased
post surgical pain.4,5,6
Temperature control at recovery room can be
done by using dry blanket to reduce heat evaporation,
and the use of warm saline solution. Warm IV saline
solution given before, during, and after surgery, is the
cheapest and easiest way to maintain core tempera-
ture, preventing hypothermia and shivering.2,3
Jie Yi et all (2013) reported that as many as
39% of surgical patients under general anesthesia
CrossMark
Aldrette’s score, body temperature, and shivering at after induction as
well as at 5, 15, 30, 60 post surgery, and at recovery room. The data
obtained were analyzed with SPSS software with a significance level of
p <0.005, with a relative risk <1 as significantly preventive.
Results: Hypothermia incidents at 5, 15, 30, and 60 minutes after
arrival at recovery room (RR) were significantly different between
groups (each p value <0.001). Shivering incidents at 5, 15, 30, and
60  minutes after arrival at recovery room (RR) were significantly
different between groups (p value <0.018, <0.004, <0.001, and
<0.001 respectively). Conclusions: The use of infusion warmer may
help in reducing the incidence of hypothermia and shivering after
general anesthesia.
experienced intraoperative hypothermia. You
Zhi-Jian et all (2011) conducted a study that in
those who did not use intravenous fluid warmed
in abdominal surgery, the incidence of shivering
was 53% (p <0,01), compared to the ones that did
use infusion warmer, where there was no shiver-
ing reported. This proves warming of intravenous
fluids during surgery can prevent shivering in post
general anesthesia.2,3
The purpose of this study was to evaluate the
effectiveness of using infusion warmer in maintain-
ing normal core temperature and prevent shivering
after general anesthesia.
MATERIAL AND METHODS
This research is an experimental non-blind
controlled trial design. This research was conducted
at the central operating theater at Sanglah General
Hospital. The research was conducted in September
to October 2016. The target population was all
patients who underwent surgery with general anes-
thesia. The samples who meet eligibility criteria were
randomized by permuted block sampling technique.
Open access: www.bjoa.balijournals.org
 ORIGINAL ARTICLE

The inclusion criteria of this study were: (1) aged Table 2  H

 ypothermia incidence after
18-60 years; (b) ASA physical status 1-2 (c) body Induction
mass index ≥ 18.5 kg / m2 or ≤ 24.5 kg / m2. While
Hypothermia
exclusion criteria were: (a) initial temperature
<36,5 °C or >37,5°C; (b) pregnancy; (c) those who B (non
A (warmer) warmer)
will undergo surgery with a high risk of heat loss; Hypothermia (n = 28) (n = 30) p
(d) received a transfusion during surgery; and (e)
Moderate 0 (0%) 5 (16,66%) 0,024a
history of frequent nausea and vomiting.
Mild 28 (48,27%) 25 (83,33%)
Shivering incidents are classified as Wrench
(1997), with 5 scales: 0-4. For the purpose of this
research, we classified Wrench’s scale of 0-1 as Hypothermia incidents are shown in Table 2
non-shivering, and 2-4 as shivering. Core tempera- and 3. Hypothermia incidents at 5, 15, 30, and
ture was measured through the ear canal using 60 minutes after arrival at recovery room (RR) were
digital thermometer. Mild, moderate, and severe significantly different between groups (each p value
hypothermia were classified as ear temperature of <0.001).
32-35 °C, 27-32 °C, and <27 °C respectively during Shivering incidents are shown in Table 4.
measurement. Shivering incidents at 5, 15, 30, and 60 minutes after
Descriptive analysis aimed to compare the charac­ arrival at recovery room (RR) were significantly
teristics of the subject by the research group. Chi square different between groups (p value <0.018, <0.004,
test is used for comparing two groups of unpaired and <0.001, and <0.001 respectively).
nominal scale. Statistical significance was assessed
with p values and 95% confidence ­intervals. p value of DISCUSSION
<0.05 was considered significant. Data analysed using
SPSS for Windows. Hypothermia is defined as a core body temperature
<36°C.4,5 Perioperative hypothermia is common
and causes severe consequences, one of which is
RESULTS post-surgical shivering. You, Xu, and Cao (2011)
Characteristics of the overall patient data are at the Department of Anesthesiology of Jiangsu
presented in table 1. We can see from Table 1 that University of China observed that the use of warm
age, body weight, BMI, and room temperature both fluids in abdominal surgery where both control
at OR and RR are normally distributed. group and test group had no significantly difference
in age, weight, height, gender, ASA, duration of
anesthesia, and fluid given. Measurement of core
Table 1  Sample Characteristics
temperature via the tympanic membrane because
Group it’s easy, non-invasive, and it has a very small bias
A (warmer) B (non warmer) ± 0,80 °C compared to esophageal temperature.7
Characteristics (n = 29) (n = 29) p value In the control group (with intravenous fluids room
Age (years) 34.14 (± 14.64) 54.89 (± 14.42) 0.026a temperature), core temperature drops to 34,9 °C
Body Weight (kg) 159.1 (± 16.32) 21.90 (±9.05) 0.759a ± 0,3 °C during the first 3 hours and then stabi-
Body Massa Index (BMI) 22.64 (± 2.95) 21.80 (± 2.58) 0.312a lized at the end of anesthesia. While the test group
Temperature at OR (°C) 22.00 (± 0.79) 21.61 (± 0.54) 0.918a (with warmed intravenous fluids) change in core
Temperature at RR (°C) 21.84 (± 0.33) 100.93 (± 0.54) 0.049 temperature decreases for 60 minutes, then stabi-
lized at the end of anesthesia. The decline in core
Duration of surgery (min) 77.24 (± 62.66) 126.79 (± 42.186) 0.239a
temperature test group is smaller than the control
Duration of anesthesia (min) 97.76 (± 68.83) 95.87 (± 45.29) 0.158a
group. They also reported shivering in 8 patients
Surgery
22 (75.9%) 19 (65.5%) with score >2 in the control group, while no one
Oncology
ENT 7 (24.1%) 3 (10.3%) was reported shivering in the test group (p <0.01). It
Orthopedic 0 (0.0%) 7 (24.1%) 0.012b showed that warming of intravenous fluids during
Sex surgery may prevent shivering after anesthesia and
Male 9 (31.0%) 11 (37.9%) maintain core temperature close to normal.
Female 20 (69%) 18 (62.1%) 0.581b From the description of characteristic data
PONV scale sample based treatment group (table 1) shows
Score 0 0 (0.0%) 4 (13.8%) that the variable weight, BMI, OR temperature,
Score 1 5 (17.2%) 7 (24.1%)
RR temperature, duration of surgery, duration of
Score 2 7 (24.1%) 4 (13.8%)
anesthesia, type of surgery, and gender in both
Score 3 12 (41.4%) 8 (27.6%)
5 (17.2%) 6 (20.7 %) 0.196b treatment groups after statistical test does not indi-
Score 4
cate any significant difference (p >0.05), so that the

Published by DiscoverSys | Bali Journal of Anesthesiology 2017; 1 (1): 10-12 | doi: 10.15562/bjoa.v1i1.3 11
ORIGINAL ARTICLE

Table 3  Hypothermia incidence at Recovery Room CONCLUSION

Minutes after
Hypothermia The use of infusion warmer was effective to prevent
arrival at A (warmer) B (non warmer) hypothermia and shivering in patients after general
recovery room Hypothermia (n = 28) (n = 30) p anesthesia. No adverse effects of nausea and
5 Moderate 0 (0%) 18 (60%) 0,001a vomiting in both treatment groups. Prevention
Mild 28 (100%) 12 (40%) of hypothermia and shivering should be done
15 Moderate 0 (0%) 15 (50%) 0,001a with multimodal either by pharmacological or
Mild 28 (100%) 15 (50%) non-pharmacological strategies.
30 Moderate 0 (0%) 16 (53,33%) 0,001a
Mild 28 (100%) 14 (46,66%) REFERENCES
60 Moderate 0 (0%) 12 (40%) 0,001 a
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Table 3 and Table 4 show that the use of warmer
can prevent the incidence of shivering and hypo-
thermia in patients after general anesthesia. Warm
IV fluids may be given before, during, and after
surgery. Warm IV fluids are easy, inexpensive, safe
and able to maintain core body temperature, to
prevent hypothermia and shivering events.

12 Published by DiscoverSys | Bali Journal of Anesthesiology 2017; 1 (1): 10-12 | doi: 10.15562/bjoa.v1i1.3